Healthcare Provider Details

I. General information

NPI: 1659249175
Provider Name (Legal Business Name): CARLIE JOANN GARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 S 76TH ST STE 305
GREENFIELD WI
53220-4364
US

IV. Provider business mailing address

4811 S 76TH ST STE 305
GREENFIELD WI
53220-4313
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7741
  • Fax: 414-325-7753
Mailing address:
  • Phone: 414-325-7741
  • Fax: 414-325-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1196-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: